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"Best Practice" in Living Donation: Quality? Quantity? Access? Pace? Yes!

There is little disagreement that transplantation is the preferable treatment option for most individuals with advanced renal insufficiency or renal failure, and that living donor kidney transplantation offers significant benefits compared to deceased donor kidney transplantation. Why is it, then, that the number of living donor kidney transplants performed in the United States has remained stagnant over the past decade?

An important approach to extending the option of living donor renal transplantation to more patients would be to identify both the barriers to living kidney donation/transplantation and the practices of highly effective groups, and disseminate that information to the transplant community. This is exactly the task taken on by the AST Living Donor Community of Practice.

I found the results of their conference so impressive that I wanted them shared with the AST membership. What follows is a summary of that meeting.

Best Practices in Living Donation

In the rare ‘easy consensus’ of the transplant world, we can agree that live donor kidney transplantation is the best treatment option for most patients with late-stage CKD. Consequently, the declining rate of living kidney donation in the US has been confounding. In spite of this, novel strategies to remove barriers to living donation have neither been effectively disseminated nor widely implemented. To address these issues, a consensus conference was held June 5-6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Initiated by the AST Living Donor Community of Practice, and built with the support of the AST Board (as well as other entities), the conference ultimately partnered 11 professional societies and 67 participants representing transplant professionals, patients, and other stakeholders. Individual workgroups (who prepared for months in advance) discussed processes for living kidney donation education; efficiencies in process; disparities in living donation; and financial and systemic barriers. The clinical, policy, and research recommendations are outlined below:

Clinical recommendations:

  • Adopt the philosophical approach that LDKT is the best option, with education integrated throughout disease progression and treatment process
  • Develop a culture supporting the LKD program, including dedicated living donor personnel, a streamlined process, careful evaluation of medically complex donors, and participation in KPD (or referral)
  • Implement an independent, national educational website for patients and the general public. Include a LKD Financial Toolkit.
  • Develop a process to ensure that transplantation specialists, community nephrologists, and primary care providers attain competency in LDKT educational content and approaches
  • Provide more culturally-tailored LDKT education
  • Systematically review live donor metrics to measure efficiencies and improve quality

Policy recommendations:

  • Actively pursue policies that achieve financial neutrality for living donors, within the framework of federal law
  • Improve and clarify CMS auditing of current transplant education within dialysis centers
  • Expand OPTN policy pertaining to required educational elements for potential living donors, to include the evolving evidence base of the potential longterm risks associated with living kidney donation (e.g., ESRD risk, future pregnancy).

Research priorities:

  • Examine effectiveness of strategies to optimize informed decision-making
  • Evaluate impact of strategies to strengthen partnerships between community nephrology, dialysis centers, and transplant programs
  • Evaluate QI initiatives to optimize the donor evaluation process and experience
  • Examine strategies to reduce financial barriers 

 Recommendations were broad and far-reaching, with more detail here.

Participants are to be commended for effectively identifying best practices in living kidney donation as well as ambitious efforts to disseminate and implement them in the transplant, ESRD, and CKD communities. We encourage all readers to participate, and to join the AST LDCOP.


Living Donor Community of Practice
Rebecca Hays, MSW APSW, University of Wisconsin Hospital – Chair
Dianne LaPointe Rudow, ANP DNP, Mount Sinai Medical Center - Past Chair
Jim Rodrigue, PhD, Beth Israel Deaconess Medical Center - Committee Member


The first concern of this group should be to ensure that selection & care of the donor is given equal or more priority than has been the case. 1. The concern for good recipient outcomes has led to an "unhealthy" use of young donors and underuse of older donors. The use of younger donors is especially concerning when lifestyle related kidney disease is the commonest cause of ESKD/requirement for Tx & one cannot guarantee that the younger donor is not going to become one of those older patients with lifestyle related kidney disease 2. A donor registry &/or better than 90% lifelong follow up of donors

Thank you for these very relevant points. We of course agree that evaluation process and care for prospective and actual living donors is of fundamental importance. Consensus Conference participants strongly recommended that prospective donors, and their supports, have access to meaningful, accurate and reliable education about the process and risks, and that this education be tailored to factors that may affect risk profile (eg. youth; medically complex older donors;etc). Indisputable changes in donor demographics (that represent a shift from past practice) merit ongoing outcomes research and adaptation of education and consent materials to accurately reflect the evolving understanding of risk. And absolutely: the clear mandate is to design and implement policies and procedures that assure all living donors have access to medical care.

Racial disparities in living donation need to be given a high priority as well - both because of the decreased opportunities for the recipients, and the still ill-defined risks to minority donors. Young or old, these are some of the most 'at risk' donors, but also the ones that we need to provide equal access for all of our patients. We know that the majority of the time donation is beneficial to both parties, and better selection tools can help us provide this opportunity to more of our disadvantaged patients.

Agreed! Although one workgroup at the consensus conference was tasked solely with exploring 'disparities in living donation,' impact of racial disparities (and other factors, including poverty and access to health care) were of high import throughout the meeting, and essential to discussion of risk, education elements and approach, and barriers to access. We appreciate your engagement and expertise, Dr Morgan, and encourage you to sign up for the COP (if you haven't done so already), to help further this discussion and dissemination of recommendations. Thanks!

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